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Paying for Team-Based Care | Complete the sentence(s) below by clicking the value that best describes the care that currently exists at your practice.

What Do Your Choices Mean?

If you score in Level D in any area, your practice is just getting started and may want to review our resources page to help you prepare for the key changes described in that section of the guide.

If you score in Level C in any area, your practice is in the early stages of change and can benefit from the action steps and resources in that section of the guide.

If you score in Level B in any area, your practice has implemented basic changes and can build upon your success with the action steps and resources in that section of the guide.

If you scored in Level A in any area, your practice has achieved most or all of the important changes required. Congratulations! You can still use the actions steps and resources in that section of the guide to find new ways to improve.

What is the business case for creating primary care teams?

In addition to serving the business of healthcare by improving the very core of our work — improving patients’ health — implementing Team-Based Care has the potential to:

IMPROVE staff satisfaction and retention

ENHANCE patient satisfaction and loyalty

POSITION clinics to capture pay-for-performance and quality improvement bonuses and grants

STREAMLINE workflow and maximize the use of staff

IMPROVE efficiency

The first step to ensuring a return on team-based care is to understand your organization’s unique financing structure. Examine your payer mix and learn what types of practice activities generate revenue. Consider:

If you are reimbursed primarily on a fee-for-service basis, you will generate more revenue by using your care team as a provider–extender, enabling more patients to see the provider for a billable visit each day

If your organization accepts full risk for patient costs, then ensuring that your patients are taught how best to manage their illness and avoid specialist or emergency room visits will likely provide a more robust financial return

If you’re paid a capitated fee for primary care services, experimenting with alternative visit types may maximize your ability to care for more patients

Because the business of healthcare is to deliver the highest quality care to patients, improving clinical performance is our driving focus. However, understanding and responding to the reality of financial pressures through increased efficiency and enhanced revenue capture is what makes clinical changes possible and sustainable.

Publications

Publications

Business Case for Behavioral Health Integration

Learn about the concept of a business case and a process to develop one, through the lens of making the case for integrating behavioral health into a primary care practice. This presentation by Roger Chaufournier highlights reimbursement considerations and resources to help you build your business case for behavioral health integration.

WorkflowTemplates, flow sheets and mapping aids

Workflow

Chronic Care Management fee Fact Sheet

Learn about the Chronic Care Management fee in this Fact Sheet from the Centers for Medicare & Medicaid Services (CMS). In recognizing the critical role of care management in primary care, CMS pays for care coordination services of Medicare beneficiaries with multiple chronic conditions.

Billing for Certified Diabetes Educators (CDEs)

Billing for Behavioral Health Specialists

Billing for Behavioral Health Specialists, such as licensed clinical social workers, depends on the payer and the state. Medicaid has national billing procedures, while Medicaid varies by states. The Center for Integrated Health Solutions offers financial worksheets for billing Medicaid in each state, which are useful for FQHCs to identify state-specific diagnostic codes and what professional credentials are needed to submit a payable claim.

ToolkitsImplementation guides and other documents with extensive resources included

Toolkits

Chronic Care Management Tool Kit

Learn what practices can do to implement and bill the Chronic Care Management codes for services provided to Medicare beneficiaries with multiple chronic conditions. This toolkit from the American College of Physicians provides clear steps and example tools your practice can use to start capturing these payments.

LEAP Learning ModuleOther helpful topics included in this website

LEAP Learning Module

Primary care function modules

Learn how high-performing teams carry out the functions of primary care, by working through modules on this website. From this link, you can choose to explore population management, medication management, behavioral health integration, and more!

Paying for Team-based care in a FFS setting

FAQ

Question

We have implemented some parts of team-based care in our practice, but are limited by our fee-for-service payment structure. How can we pay for nurses and other team members to do more?

Answer

Most practices are paid FFS. Even additional pots of bonus money for quality or minimal PMPM payments for care coordination leave unchanged the fundamentals of FFS. This is a common issue. Caring for more patients with the same number of providers is a reality in a FFS setting.

Familiarize yourself with level-one evaluation and management office visit codes (E/M). For example, CPT code 99211 is an office or other outpatient visit that “may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing/supervising these services.”

New payer codes for Medicare preventive visits, transitions of care, and care coordination do not require a physician.

Question

Our patients are covered by all kinds of different payers, how do we create a coherent care team model in this kind of environment?

Answer

Primary care practices are faced with many different payers and many different and sometimes conflicting financial incentives. Excellent, demonstrable quality of care will go far in helping you make a financial case to your payers and healthcare partners (e.g., area hospitals). Keep in mind, too that revenues are only one side of the equation. Reducing costs benefits all practices, regardless of payer source.

Question

There is a lot of talk about risk sharing arrangements where primary care practices could benefit from managing patient health and utilization. (e.g., Accountable Care Organizations, cost sharing arrangements, value-based contracts, or pay for performance). Can team-based care help me financially in these new arrangements?

Answer

Yes. May have upside or both upside and downside risk. In any case utilization and quality are concerns. Evidence shows executing well on the functions described in this guide are likely to help.

Question

Can I bill for services provided by a certified diabetes educator or a licensed clinical social worker?

Answer

Billing for CDEs depends on the payer. Billing for behavioral health specialists, such as licensed clinical social workers, depends on the payer and the state.

If you have a question about the improvements, action steps, or tools & resources in this module please let us know. We're here to help. And if we can't answer your question, we can probably connect you with someone who can.